Yep, here we are the next morning with a new puzzle to figure out.
They gave in last night and let him start having water. He was allowed 30 mL per hour. That is one ounce per hour. That is two tablespoons per hour. He opted to split that up into two doses, so he was taking one tablespoon of water each half hour. He actually admitted that his stomach was a little upset after he started taking water (maybe the surgeons know how to advance a diet after surgery after all).
Last night his pain was controlled well enough that he sat up in bed. He laid on his side for a while. He built a Lego set that had been given to him. He was more talkative and seemed to have more energy. Everything has looked better than all of last week.
But then, this morning happened. His blood counts came back with a concerning finding. His white blood cells have remained high the way someone with an infection and recent recovery from having no white count would. His platelets have remained a little high. But his hemoglobin dropped a large amount. His last lab was from before the surgery and was still below normal, but improved from it's lowest point after chemotherapy. The oncologists have 7 as a threshold for giving a blood transfusion (unless there are other clinical reasons to do so) and he had come as low as 7.2 before we found the abscess, but his hemoglobin had risen to almost 9. This morning it was 6.8. Head scratching begins, and here are the options (what we call a differential diagnosis) and some thoughts about those.
Lab error. Really common for big drops in hemoglobin to be due to a lab error. The best course of action is to hurry and send a new sample and make sure the value is correct (unless all other aspects of the patient suggest that it is real, see more below). Usually, if there is an error, it affects other lab values as well. Everything else looked fine, so the chance that this is simply some sort of error is pretty low.
Dilution. Too many fluids, particularly during surgery could do it. However, we would expect all other lab values to be abnormal as well, so not a very likely explanation. Plus, we have kept plenty of fluid in him all along, so he should tolerate the fluids at surgery better than someone who had been sick at home for a few days and not drinking well, who may be a bit dehydrated.
Bleeding. Pretty common reason for the hemoglobin to drop. With this amount of drop we would expect to see other signs of it. His heart rate should go faster (it has been slowing down since the infection and surgery). The most likely place for him to bleed would be where the abscess was or along the incision. He has drains in both of those places and there isn't any blood there. We would expect him to have trouble breathing if it were in the lungs, or pain if it were in any other location. We would expect to see a large bruise if it were anywhere near the skin.
Hemolysis. The red blood cells can become fragile for reasons and they can break apart. This tends to cause some other lab abnormalities, which aren't there, but this could still be an explanation. Fortunately oncologists also get training in blood disorders, and the oncologist should be able to figure this problem out.
Sequestration. The body is hiding his blood cells somewhere, usually the spleen. This seems like an unlikely explanation to me, but I'm not totally up to speed on this. The most common group of people who get sequestration in the spleen are people with sickle cell disease. Their sickle shape blood cells don't pass through the spleen like the normal flexible disk-like red blood cells and they get trapped. The spleen works to pull out old red blood cells from circulation, so any damage to the cell itself can lead to it getting pulled out of circulation.
The plan right now is to repeat labs. If it's truly low, they will give him some blood cells. We'll check and make sure he has an appropriate response and that it doesn't keep going down. If it keeps going down, we need to figure out why.
And things were going so well.
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